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August 1979 

VADM Willard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM H.A. Sparks, MC, USN 

Deputy Surgeon General 

Director of Public Affairs 

LTJG Richard A. Schmidt, USNR 


Jan Kenneth Herman 

Assistant Editor 

Virginia M. Novinski 

Editorial Assistant 

Nancy R. Keesee 


Vol. 70, No. 8 
August 1979 

1 From the Surgeon General 

2 Features 

Medical Service Corps: Progress and Plans 
CAPTP.D. Nelson, MSC, USN 

Contributing Editors 

Contributing Editor-in-Chief; CDR E.L. Tay- 
lor (MC); Dental Corps: CAPT R.W. Koch 
(DC); Education: LT R.E. Bubb (MSC); Oc- 
cupational Medicine: CDR J.J. Bellanca 
(MC); Preventive Medicine: CAPT D.F. 
Hoeffler (MC) 

POLICY: U.S. Naiy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy-, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: V.S. N<ny Medicine is distributed (o 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical. Dental. Medical Service 
and Nurse Corps officer: one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. rlfinvy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor. U.S. Navy Medicine. Department of 
the Navy, Bureau of Medicine and Surgery ICode 0010>, 
Washington. D.C. 20372. Telephone: (Area Code 2021 254- 
4253. 254-4316. 254-4214: Autovon 294-4253. 394-4316. 294- 
4214. Contributions from the field are welcome and will be 
published us space permits, subject to editing and possible 

The issuance of this publication is approved in accordance 
with Department of the Navy Publications and Printing 
Regulations (NAVEXOS P-3S). 

6 Cluster Well-Baby Clinic 
CDR CM. Cronin. NC, USN 

8 New BUMED Alcohol Rehab Instruction 

10 Education and Training 

U.S. Navy Cold Weather Medicine Training Course; A Challenge 


IT D.C. Arthur, MC, USN 

14 Continuing Education in the Nurse Corps 
CDR F. C. McKown. NC, USN 

16 Professional 

Intraoral Removal of a Large Submandibular Gland Sialolith 

CDR M. T. Ridley, DC, USN 

LCDR R.S. Jones, DC, USN 

LT G.B. Ingraham III, DC, USNR 

18 Nutritional Support: The Use of Assessment Principles and a 
Nutritional Preparations Formulary 
LT S.R. Lamar, MSC, USN 
L.S. Hursig, RD 

26 Notes and Announcements 


COVER: LTJG Deborah E. Bane, NC, administers polio vaccine at the 
Cluster Well-Baby Clinic, NRMC Corpus Christi, Tex. Photo by HM3 
D.E. Evans. 



The Naval Reserve: A Vital Part 
of the Total Force Concept 

Early in his First year as Chief of 
Naval Operations, ADM Thomas B. 
Hayward, USN, issued seven 
"goals and objectives." One was to 
revitalize our "One Navy" approach 
to contingency planning. He made it 
clear that he would be involved, 
along with the rest of the Navy 
chain of command, in considering 
how the Naval Reserve can con- 
tribute to our Total Force concepts 
of mobilization. With this statement 
of concern by the Chief of Naval 
Operations, the Navy Medical De- 
partment has reviewed its status. I 
have held several meetings with the 
Reserve Medical Flag officers and 
urged that the Medical Reserve 
Policy Board present its recommen- 
dations. In concert with the Army 
and Air Force Surgeons General, a 
report relating to Reserve medical 
matters was forwarded to the As- 
sistant Secretary of Defense for 
Health Affairs in November 1978. It 
was evident from the report that a 
major concern was the shortfall of 
junior medical officers and hospital 
corpsmen, and that recruiting and 
retention of Reserve physicians and 
hospital corpsmen needed priority 
consideration. Data indicated that 
the vital support of dental officers 
and dental technicians, Medical 
Service Corps officers, and Nurse 
Corps officers was being met with 
very few SELRES billets available to 

accommodate many highly qualified 
and motivated personnel. 

Every year our activities in and 
around BUMED are stimulated by 
studies and exercises. Operation 
"Nifty Nugget," a 30-day evolution 
involving the Joint Chiefs of Staff 
and all the CINC's around the 
world, dramatically demonstrated 
how vital the Naval Reserve is in 
providing the Total Force capabili- 
ties that our contingency planners 
forecast. That particular exercise 
revealed many shortfalls, but none 
as critical as the lack of hospital 

A recently completed review of 
our Medical Department Reserve 
components concluded with the 
recommendation that the previously 
successful operational Reserve hos- 
pital units be re-established. It is 
anticipated that by 1 Oct 1979, we 
will have 101 Medical Contingency 
Reserve Units (MEDCRU's) on line 
with mobilization affiliations to our 
Navy regional medical centers. This 
program has the support of the 
Chief of Naval Operations, Chief of 
Naval Reserve, Commandant Ma- 
rine Corps, and Chief of Naval 
Personnel. It is clear that the Medi- 
cal Department Reserve represents 
a cadre of talented, dedicated, and 
patriotic men and women who are 
willing and ready to serve their 
country in time of need. 

Total Naval Force requirements 
are determined by the national mili- 
tary strategy. The roles and tasks 
assigned to the U.S. Navy deter- 
mine the structure of a Naval Re- 
serve force necessary to support the 
Navy's mission and functions. 

It is important that everyone un- 
derstand the Navy organization, its 
mission, and how it functions so 
that we can "talk up" the Navy in 
our communities. You must have 
the ability to articulate the Navy's 
needs in clearest terms. I call upon 
each of you to bear some of our 
burden of recruiting and retaining 
capable people in our active and 
Reserve forces. We must have a 
capable Navy, and the American 
people need to hear our story. We, 
in the Medical Department, feel 
that our responsibilities are being 
met by capable, ready, and willing 
personnel. "One Navy" is not 
rhetoric but a viable, vital necessity 
for mobilization. 

I ask for your "total team sup- 
port" and hope you will do your 
share to make certain that our Navy 
remains second to none. I know you 
will and can do it! 


Vice Admiral, Medical Corps 

United States Navy 

Volume 70, August 1979 

Medical Service Corps: 
Progress and Plans 

CAPT Paul D. Nelson, MSC, USN 

In the August 1978 issue of U.S. Navy Medicine, I out- 
lined what I considered to be among the major chal- 
lenges and opportunities facing Medical Service Corps 
officers as we look to the future. I did so with assistance 
from several of our senior officers, varied in profes- 
sional specialty and service background, who shared 
their thoughts on "where we are" and "where we need 
to go." Revealed in that sample of opinions was a sense 
of diversity — diversity of problems, proposed solutions, 
professional aspirations, but also of available talent. 
But there was something else, too, in what those offi- 
cers shared — a sense of common commitment and 
loyalty, a singularity of purpose achieved through dif- 
ferent but equally distinguished naval service careers. 
My concluding charge to Medical Service Corps officers 
at that time was that we move forward together, with 
others of our Medical Department colleagues, in an at- 
titude of "many talents, one team, one spirit." Now, 
one year later, I am even more convinced that we must 
do so, indeed. And I believe we are. 

For the Medical Service Corps, fiscal year 1979 has 
been a year of inventory, of taking stock. It has also 
been a period of change. Our emphasis in all such 
activities has been on professional matters — to increase 
opportunity, challenge, and commitment. It was not 
only proper, therefore, but essential in my opinion that, 
under the recent BUMED reorganization, our Medical 
Service Corps Division return to a place alongside each 
of the other Medical Department Corps. For, with the 
interdependency of professional and technical roles in 
all phases of health care services, matters of profes- 
sional development in any one corps potentially affects 
each of the others as well. Hence, we must work more 
closely together. And it is in that context that we have 
proceeded this year. 

Better Communication 

Perhaps the activity which has most characterized 
the Medical Service Corps Division this past year is that 

CAPT Nelson is director of the Medical Service Corps. 

of meeting people. It has been central to the process of 
taking stock. It has also been central to whatever 
change has occurred in policy, practice, or procedure. 
We meet with purpose — to define or solve problems, to 
plan and develop programs, to become better informed 
about policies or procedures, to sample points of view 
about issues, or simply, but importantly, to get to know 
one another better, personally and professionally. 

We have met with colleagues from most other 
BUMED divisions, with colleagues of other services, 
with the Navy and Marine Corps line, and with our 
officers from field activities. Because of the diversity of 
roles among Medical Service Corps officers, there are 
very few issues or institutions in health care service 
with which we do not have some relationship. Hence, 
the problem areas about which we meet are great in 
number and vary in complexity. As time consuming as 
this is, it is absolutely essential if we are to effectively 
communicate and work together as one Medical De- 
partment team. That is our intent, and I think we are 
making some progress, in the field as well as at BU- 

The principal catalysts in this communication process 
within the Medical Service Corps Division are CAPT 
Cherry Hatten, Deputy for Health Care and Sciences, 
and CAPT Vic Swindall, Deputy for Health Care Ad- 
minstration, each of whom is responsible for profes- 
sional areas which embrace about 50 percent of our 
Medical Service Corps officers at this time. Other 
Medical Service Corps Division staff officers responsi- 
ble for various aspects of our professional program 
development efforts are: LCDR Bob Brant who coordi- 
nates assignment and career planning, LT Ken Gibson 
who coordinates special analyses of our billet require- 
ments and officer resources, and LT Bob Rodell (now at 
NRMC Memphis) who coordinated our procurement 
and officer accessions. LCDR Sal Profita has just 
recently joined our Division staff as well. The Division 
staff is also assisted by nearly 30 officers who serve as 
professional advisors in specialty areas of health care, 
science, and administration in which Medical Service 
Corps officers function (see List) . 

U.S. Navy Medicine 

This past year, in addition to increasing the profes- 
sional specialty areas and number of advisors in the 
health care administration field, we also appointed ad- 
visors for special institutional areas of service (e.g., 
Marine Corps, research, dental, education, etc.). 
Though in need of further refinement, this advisory 
system enables us to productively involve more officers 
in the process of reviewing policies and problems. It 
also allows us to simultaneously evaluate issues and 
problems affecting Medical Service Corps officers from 
both a professional discipline and institutional perspec- 
tive. The advisors, in turn, are expected to be com- 
munication links to communities of officers in the field 
whom we encourage, of course, to meet just as the ad- 
visors do across professional disciplines within their re- 
spective field commands on many of the same problems 
and issues. 

Getting Out in the Field 

In addition to meeting with people at BUMED, it is 
our plan and it has been my privilege to visit our field 
activities. With solid support from the Surgeon Gener- 
al, I was able this past year to visit in CONUS about 60 
percent of our naval hospitals and regional medical 
centers, 50 percent of our dental facilities, 90 percent of 
our training facilities, 80 percent of our environmental 
and preventive medicine facilities, 70 percent of our 
research facilities, and 60 percent of our headquarters 
and other staff activities. I visited officers who work in 
the shipyard environment, aboard ship, and with the 
Fleet Marine Force. I met with nearly all of our newly 
commissioned officers for informal exchange and with 
those officers in the several new health care administra- 
tion short courses at the Naval School of Health 
Sciences, Bethesda, Md. In all, I have met with, either 
personally or in groups, what I estimate to be over 900 
officers, half of our Corps strength. In so doing, I tried 
to learn from the perspective of the officer in his or her 
duty environment, Consequently, I made an effort to 
meet with other Medical Department and line officers 
with whom and for whom we serve. I plan to continue 
doing this for it has given me much greater apprecia- 
tion for the problems faced by our Medical Department, 
the aspirations and concerns of our officers and petty 
officers as well, and respect again for the great diver- 
sity of talents available to us. 

For those who serve in the more remote activities, 
who may be at sea or on overseas deployment, but 
whom for one reason or another it has been difficult for 
me to visit to date, let me assure you at this point that 
you are not forgotten. The greater than usual sacrifice 
you and your families make in many such instances is 

Medical Service Service Corps officers who served 
as specialty advisors during FY 1979 are: 

Health Care Administration/Institutional Advi- 

CAPT L.E. Angelo (Data Processing/MIS) 
CAPT L.B. Nichols (Facility Construction) 
CDR G.S. Harris (Marine Corps) 
CDR A.D. Hatten (Patient Services) 
CDR J.J. Kehoe (Dental) 
CDR C.R. Loar (Quality Assurance) 
CDR R.F. McCullagh (Fiscal /Supply) 
CDR O.L. Wood (Research) 
LCDR E.A. Donohue (Naval Reserves) 
LCDR A.W. Frost (Food Service) 
LT J. A. Kramer (Education/Training) 

Health Care and Science Advisors 

CAPT E.S. Hochstein (Podiatry) 

CAPT S.W. Joseph (Bacterial/Microbiol/Para- 

CAPT M. Springer (Dietitian) 
CDR W.M. Beckner (Radiation Specialties) 
CDR R.J. Biersner (Research Psychology) 
CDR A.R. Dasler (Physiology) 
CDR H. Delaney (Occupational Therapy) 
CDR R.S. Gibson (Aero Psychology) 
CDR J.R. Lucas (Pharmacy) 
CDR R.D. McCuIlah (Clinical Psychology/ Social 

CDR P. McKelvy (Physical Therapy/Med Spec 

CDR J. A. Mulrennan (Entomology) 
CDR W.M. Parsons (Environmental Health) 
CDR D.H. Reid (Aero Physiology) 
CDR L. Roach (Optometry) 
CDR D.E. Uddin (Chem/Biochem/ Pharmacol) 
LCDR C.W. Baker (Industrial Hygiene/ Audiol- 

LCDR D. Schubert (Medical Technology) 

very much appreciated. But regardless of where you 
serve, with continued good performance, you will not 
"drop a stitch" in your career progression. Each as- 
signment should be an important learning step in your 
career. If it hasn't been to date, we plan to make it that 
way in the future. I am fully aware that there are many 
duties less popular and certainly less comfortable than 
others. But all are essential. We need every bit of the 
high quality in officer performance at those assign- 

Volume 70, August 1979 

MSC Roles in Operational and Clinical Settings 

LCDR W.M. Parsons, MSC (left) aboard the USS Mahan for An MSC officer reviews strip chart recordings during evalua- 
an environmental health consultation. tion of personnel radiation dosimeters. 

ments as we do at the more visible and popular assign- 
ments. Just this year, for example, we increased by 
request the number of Medical Service Corps officers 
assigned to Navy recruiting, a most critical problem 
area for our Medical Department and for the Navy in 
general. And, we selected top performers to do the job. 
The same is true for such other assignments as the 
Fleet Marine Force, shipboard duty, and BUMED duty, 
as well as in our selection of Medical Service Corps 
candidates for staff and command colleges of the ser- 


At the middle to senior grade levels our executive 
assignment slates this year were based upon several 
criteria of officers qualification; 

• performance, 

• type and variety of duty experience, 

• professional achievements and honors, 

• education, and 

• leadership qualities matched against Navy needs 
and billet requirements. 

Interests in a particular assignment are certainly con- 
sidered, but only after an officer appears professionally 
qualified for that assignment. 

We are also striving to challenge our officers with 
higher levels of responsibility as early as possible but 
without giving too much too soon. A few of those as- 
signments are perhaps seen by some to be wrong or at 
least contrary to what has been. That will probably 
always be the case. But we must recognize the variety 
of talents required in our total mission and also be 

aware that those talents exist to different degrees in 
different persons. And we must identify and cultivate 
these talents early in our officers' careers. For some, 
the flair for leadership is less of a personal capability 
than strength in a technical area. In others, the 
opposite might be true. Some may be better in field 
command situations; others are perhaps better head- 
quarters staff executives. The point is, however, that all 
are important in the overall mission. And we are in 
critical need of all such talents in our senior officers. 
We need the technical specialist every bit as much as 
the generalist, the officers for staff as well as for com- 

Career Development 

This finally brings me to the issue about which our 
officers seem most concerned, one about which I am 
most frequently asked questions, and one about which 
there appears to be little information available. That is 
the issue of career planning. I mentioned it in my article 
in U.S. Navy Medicine, August 1979 and the Surgeon 
General wrote about it in his January 1979 letter to all 
Medical Service Corps officers. By virtue of our mutual 
regard for its importance, it is the top priority issue for 
the Medical Service Corps Division in fiscal year 1980. 
Our objective is to develop prototype career planning 
models for all Medical Service Corps specialties by this 
time next year. They should be sufficiently general as 
to be flexible, a necessity in our changing environment. 
However, they must also be sufficiently specific to be 
useful to individuals and groups of officers. 

The career planning models should benefit man- 
power planning, resource budgeting and acquisition, 

U.S. Navy Medicine 

the development of officer education, training, and as- 
signment policies. The local commands and our 
Medical Service Corps advisors must also find them 
suitable for personal officer counseling and guidance. 
We will strive to give officers some choice at various 
points along the way. But we must also develop models 
which enable us as a professional corps of the Medical 
Department to meet the requirements of our mission 
under standard and contingency conditions of opera- 
tion. As officers of different professional specialties in 
health care services, our roles will not be the same, nor 
will our preparation for those roles. But as officers of 
the Navy Medical Department, we must be commonly 
aware of our mission, committed to its fulfillment, and 
prepared in whatever way appropriate to serve toward 
that end. 

With career planning models, we can more meaning- 
fully address such issues as the following: specializa- 
tion vs. generalization, tour rotation and assignment 
policies, inservice vs. direct procurement, education 
and training requirements, mid-career shifts in 
specialty area, operational and staff duties, and oppor- 
tunities for executive growth. Realistically, I am well 
aware of the personal and situational forces that shape 
the careers of men and women. But models are not 
necessarily prescriptions for any one individual's 
career. Rather they should be regarded as aids by 
which to plan in more systematic ways, hopefully with 
mutual benefit to the individual and organization. We 
have much work to do, and we need the help of every- 
one before we are through. Meanwhile, a number of 
activities have already been initiated this year. 

New Options 

Under the direction of CAPT Hatten and CAPT 
Swindall, with contributions again from the specialty 
advisors and other BUMED staff, we have begun to 
analyze current and potential requirements for Medical 
Service Corps officers of all specialties under standard 
and various contingency conditions. Those require- 
ments must be the basis for our billet structure, which 
we are also reviewing at this time in terms of profes- 
sional function. 

Simultaneously, the Navy SHORESTAMPS program 
is approaching the billet structure from a workload per- 
spective. We are remaining abreast of that effort. In the 
final analysis, the need for billets and the professional 
functions performed therein determine the organiza- 
tion's requirements for a career plan. They should 
guide our specialty requirements, our education and 
training, and our assignment strategies. But we must 
also consider the individual's interests, attitudes, and 

goals. For, until we know something of the latter, we 
cannot attempt to strike a balance between the individ- 
ual's and the organization's needs. 

Consequently, through the contributions of our 
specialty advisors and other BUMED offices as well as 
from the Naval School of Health Sciences, we have 
already assembled a variety of draft career plan options 
for many of the Medical Service Corps specialty areas, 
administrative, scientific, and clinical. While that effort 
continues, we are also planning a study of our Medical 
Service Corps officers, how they view their professional 
careers, the organization, and their jobs. Proposed for a 
start in fiscal year 1980 and now in final design stage, 
the study will be conducted through the staff of the 
Naval School of Health Sciences, in collaboration with 
the Naval Health Research Center, San Diego, Calif. In 
time, it is anticipated that the resulting data will be 
useful in fine-tuning the initial prototype career 
planning models for Medical Service Corps officers. 

The Future 

In balance, this has been a busy year and a produc- 
tive one. We have more billets to fill than we did a year 
ago due to expansion of such health care services as 
clinical psychology, pharmacy, and medical technology. 
We also obtained OPNAV approval for two new special- 
ties, clinical audiology and social worker, to further 
extend our capability at selected Naval Regional Medi- 
cal Centers. Overall, we project about 1,850 officers on 
board by fiscal year end, about 60 percent of whom are 
billeted in patient care activities. But we are increasing 
our emphasis, as well, on billets which directly support 
the fleet, especially in the various science specialties 
related to preventive, occupational, and industrial 

In all, our Medical Service Corps officers serve in 
approximately 250 different commands and staffs. In 
more than 20, they serve as commanding officer. In 
more than 40, they serve as officer in charge. The op- 
portunities for executive growth are not only in field 
commands, but in senior headquarters staff positions of 
fleet and shore establishments alike. And though we 
are short of authorized strength in our senior grades, 
the potential is there for our permanent career officers 
who comprise about 65 percent of our overall strength 
at this time. 

Though we have problems, I believe the health of the 
Medical Service Corps is sound; certainly, the profes- 
sional challenge has never been greater. As we mark 
our 32nd anniversary as a Corps, let us unite behind the 
leadership of the Surgeon General and enter the new 
decade ahead as "partners in productivity." 

Volume 70, August 1979 

Cluster Well-Baby Clinic 

CDR Claire M. Cronin, NC, USN 

Minutes! Hours! Quality time! Quality Care! Everyone 
connected with health care has struggled with the prob- 
lem of making the best possible use of clinic hours for 
quality health care. One innovative solution to this 
problem. Cluster Well-Baby Clinics, is working at the 
Pediatric Clinic, Naval Regional Medical Center, 
Corpus Christi, Tex. 

Inherent Difficulties in Traditional Approach 

The traditional approach to well-baby care — a series 
of 20-minute individual appointments — had some in- 
herent difficulties. Answering the same questions for 
12 to 15 mothers, was physically and mentally exhaust- 
ing. Trying to cram basic infant health care into 20 
minutes along with examining the child and giving im- 
munizations did not leave enough time for individual 
problems or concerns that the parents might have. The 
obvious solution was to restructure the time we were 

The nursing literature reports a successful trial con- 
cept of group well-baby visits. (/) In the early sixties 
at another military facility, the clinic's Chief of Pediat- 
rics, Dr. M.A. Woodall, innovated lectures to groups of 
mothers prior to the well-baby examinations. In addi- 
tion, we had successfully used group teaching in our 
prenatal classes and postpartum discharge classes. 
Based, then, upon past experiences and present need, 
the following cluster program was organized. Initially 
well-baby appointments were scheduled for six weeks, 
three months, and six months after birth. The reorga- 
nized time schedule allowed us to expand to two-week, 
two, four, and six-month appointments as well. The 
visits were planned as following. 

Cluster Well-Baby Clinic Schedule 

0800-0815: Check-in Time. The nurse staff obtains 
measurements of weight, height, and head circumfer- 
ence of all babies. The appropriate well-baby forms are 
completed including dietary history and any current 

0815-0830: Educational film strips are shown, ap- 
propriate for age groups on such topics as feeding, 
safety, infant communication, and normal growth and 

CDR Cronin is assigned to the Naval Submarine Medical Center, 
New London, Groton, Conn. 06340. 

Reprinted with permission of Pediatric Nursing, 5(2), March/ April 

0830-0900: A lecture by the pediatric nurse practi- 
tioner is followed by discussion and questions and 

0900-1000: Individual exams are performed by the 
pediatric nurse practitioner and pediatricians. Indi- 
vidual problems are handled at this time. Immuniza- 
tions are given after the exam. 

Repeated Instructions Replaced 

Replacing the often-repeated instructions to each in- 
dividual mother is a lecture by the pediatric nurse 
practitioner. Lecture topics are structured to relate to 
the age of the babies scheduled to be seen. In the 
two-week clinic, for example, information concerning 
infants' crying, feeding, problems with colic, and 
maternal and infant bonding is stressed. In subsequent 
clinics, such topics as growth and development, nutri- 
tion, safety, immunizations, teething, toys and play, 
and family relationships are discussed. 

Emphasis is placed on the psychologic as well as the 
physical needs of both infants and parents. Besides the 
concept of maternal/infant bonding, information about 
infant stimulation and learning needs, separation 
anxiety, and sleep disorders is provided by the nurse 
practitioner. There is opportunity to educate as well as 
reassure parents, especially those experiencing parent- 
ing for the first time. 

Recent concepts in infant nutrition are taught, in- 
cluding the need for iron-fortified formula until one 
year of age, delaying introduction of solid foods until 
six months of age, and the risks of obesity and iron- 
deficiency anemia. Parents are instructed how to make 
their own baby foods, how to intelligently read baby 
food labels, and how to choose baby foods. 

At the end of the lecture, the parents receive a 
printed sheet of information covering all the topics dis- 
cussed. They are also urged to take home the many 
educational pamphlets available in the clinic concern- 
ing the same subjects. 

Question and Answer Session 

A question and answer session immediately follows 
the lecture. The session has numerous advantages. 
Experienced mothers add helpful information and 
support. Inexperienced mothers realize that theirs are 
not isolated problems, and they are not necessarily 
"bad" mothers because their child cries or refuses to 
eat, etc. Parents share opinions of baby products which 
is helpful, especially to novice mothers. 


U.S. Navy Medicine 

The parents benefit, and so does the pediatric nurse 
practitioner. The question and answer sessions supply 
me with much practical, common-sense information on 
child care. In addition, I am able to obtain feed-back 
from previous clinics. For example, a common problem 
is a parent's concern over reactions to immunizations. I 
can ask, "Were you prepared adequately for the reac- 
tion?" In most cases, the answer is "yes." 

The question and answer session also allows for a 
supportive atmosphere to develop among the attending 
parents. At a recent two-week clinic, an exhausted 
mother of two asked, "How can I get my husband to 
help me care for the children. He feels they are my re- 
sponsibility." Several parents in the group immediately 
responded with tales of similar experiences. The young 
mother eventually followed their advice to initiate frank 
discussions with her husband easing the situation. 
Would this problem have surfaced during a traditional 
visit? Now, I remember to raise the question in my dis- 
cussion of parents' roles. 

The lectures with their question and answer sessions 
provide opportunities for parents to observe similarities 
and differences among a variety of infants. For exam- 
ple, during a fourth-month clinic, a mother of a breast- 
fed baby noted that he looked much smaller and under- 
weight in comparison to the other babies. The baby did, 
indeed, have a decided drop in weight and the problem 
was subsequently corrected. 

Another mother in the sixth-month clinic noted that 
her seven-month-old did not favorably compare in de- 
velopment in comparison with the other babies. This 
child is presently being evaluated for developmental 
delays. The parents have welcomed this opportunity 
that they otherwise would not have had. 


In analyzing the program, advantages can be deter- 
mined for both parents and medical staff. The program 
allows mothers to meet and share mutual problems and 
concerns. A common remark is, "It helps to know that 
I'm not the only one with that problem." The empathic 
atmosphere is vital to military families, many of whom 
are headed by young, inexperienced, low-income 
parents thousands of miles away from friends and rela- 
tives. The clinic provides an extended-family atmo- 
sphere that is psychologically supportive as well as pro- 
viding medical care and treatment. 

The indepth educational program including the film 
strips and lectures provides 45 minutes of educational 
time that covers many more topics than the individual 
20-minute appointments could not offer. 

Since the program is designed specifically for well- 

babies, there is little or no exposure to sick children. 
The Well-Baby Cluster Clinics are held regularly two 
days a week from 0800 to 1000. The emphasis is entirely 
on caring for the healthy child. 

The advantages to the professional staff are numer- 
ous. Primarily there is a better use of physicians' and 
nurse practitioners' time. For example, three care 
givers can now provide care to 15 babies in one hour's 
time. Under the previous structure of individual 20- 
minute appointments, this would have required five 
hours of clinic time. A 40 percent increase in time saved 
demonstrates the efficiency of the program. 

Another plus has been the increased job satisfaction 
for all the members of the clinic staff. There has been a 
noticeable increase in the nursing staff's interest and 
participation since the program began. The first hour of 
the clinic depends heavily on the efficiency of the 
nursing staff in completing the weighing, measuring, 
etc. The staff is now able to recognize and identify 
potential problem areas and bring them to the attention 
of the medical team. 

Another benefit of the program has been the expan- 
sion of health services at a time when staffing was 
reduced. The addition of two-week, two- and four- 
month visits to the schedule of six-week, three-month, 
and six-month appointments has fulfilled definite needs 
in the overall health care of these children. Problems 
are now more quickly detected before they become 
major complications. 


Some disadvantages are inevitable in any 
system. The limited choice of times for appointments is 
a problem for some parents. Working mothers may 
have difficulty participating. Although further research 
needs to be completed, it appears the group approach 
may not allow for the one-to-one relationships to de- 
velop between the parent and the health-care giver as 
the traditional appointment system allowed. 

The cluster well-baby approach is appropriate only 
for younger babies, birth to six months of age. At 
times, the noise level during the sessions is a problem. 
Having volunteer workers available to comfort crying 
babies might alleviate this drawback. 

Parents' Response to Cluster Clinics 

A questionnaire was developed to survey parents' 
opinions of the newly developed cluster clinic. Parents 
were asked to evaluate check-in procedures, the clinical 
staffs' attitudes, the educational film strips, the lecture 
by the pediatric nurse practitioner, the lecture discus- 
sion, the question and answer session, and the indi- 

Volume 70, August 1979 

vidual baby examinations by the practitioner/pediatri- 
cian. Comments or suggestions they had for improving 
the health care procedures were also requested. 

The evaluation of the clinic since its initiation in May 
1977, has been generally positive. Approximately 90 
percent of the respondents indicate they prefer to 
attend the cluster clinic rather than return to individual 

Practitioner's Response to Cluster Clinics 

My own response to the cluster clinics is extremely 
positive. I have time for teaching parenting. There is 

time to provide the "whys" for parents not just the 
"hows." Time is available to better care for the psy- 
chologic as well as the physical needs of my patients. 
Health care has improved through the establishment 
of the two-week post-hospital discharge clinics allowing 
for early detection of newborn problems. The closer 
followup between visits has resulted in fewer problems 
with feeding, obesity, and colic. 


1. Feldman M: Cluster Visits, Amer J Nursing 74:1485-1488, 
August 1974. 

New BUMED Alcohol Rehab Instruction 

The Bureau of Medicine and Surgery has revised its 
Alcohol Rehabilitation and Treatment Instruction to 
clarify procedures for admission and discharge to 
Alcohol Rehabilitation Services. BUMEDINST 6330. 2B 
of 21 May 1979 includes some additional requirements 
which the Navy medical community should be aware of. 
These new requirements are summarized below: 

Acceptance of Intoxicated Personnel in 
Emergency Rooms 

BUMEDINST 6330. 2B includes a provision that 
"Personnel presented to emergency rooms of medical 
facilities suffering from prolonged or severe quantita- 
tive ingestion of alcohol will be admitted for detoxifica- 
tion in accordance with OPNAVINST 6330.1, whether 
or not withdrawal symptoms are imminent. ' * The above 
statement was incorporated into BUMEDINST 6330. 2B 
because emergency room attendants often overlook 
important symptomatic indications to "avoid admitting 
the drunk" who may be disruptive and difficult to 
handle. Activities are cautioned not to turn away intoxi- 
cated personnel who in fact may need treatment and 
detoxification. Failing to admit obviously intoxicated 
personnel who exhibit impairment of judgment or 
physical dysfunction creates an important ethical con- 
sideration for the admitting facility. The patient could 
receive serious bodily harm or even die from aspiration 
of gastric contents, seizure, or accidents influenced by 
the intoxication. In the past, intoxicated personnel who 
were turned away from emergency rooms, and who 
injured or killed themselves or others were generally 
not an embarrassment to the contact facility. Today, the 
public, press, and courts demand that treatment facili- 
ties give account of their actions. 

Criteria for the Diagnosis of Alcoholism 

BUMEDINST 6330. 2B directs medical department 
personnel to utilize NAVMED P5116, "Drug Abuse 
(Clinical Recognition and Treatment, Including the 
Diseases often Associated)" when dealing with intoxi- 
cated personnel or when reviewing medical records ex- 
hibiting symptomology of alcoholism. Especially help- 
ful is Appendix E concerning "Criteria for Diagnosis of 
Alcoholism." This publication should be available to all 
physicians and emergency room personnel. Copies can 
be obtained from the Bureau of Medicine and Surgery 
(MED-53), Navy Department, Washington, D.C. 20372. 

Blood Alcohol Levels 

BUMEDINST 6330.2B requires that a test for blood 
alcohol level be conducted for all patients seen in emer- 
gency rooms whenever the practice of good medicine 
requires it. Although many consider such testing as an 
invasion of privacy, it is considered a good practice to 
insure that blood alcohol levels are known and recorded 
by emergency room personnel. There have been cases 
in the past where personnel with heavy alcohol intake 
have been admitted for treatment for reasons other 
than alcohol intoxication. They have not necessarily 
exhibited the symptoms of drunkenness due to a high 
tolerance for ethanol. There is a danger of administer- 
ing drugs to these patients which may have a syner- 
gistic effect with alcohol. Additionally, there are 
recorded cases where personnel have been admitted for 
treatment with high alcohol intake not apparent at 
admission, who have developed serious ethanol with- 
drawal complications. It is essential that emergency 
room personnel insure that blood alcohol levels are 
recorded whenever doubt exists. 

U.S. Navy Medicine 

Recent Publications by Navy Authors 

The following are papers published or issued by 
Naval Medical Research Institute military and civil- 
ian investigators atNNMC Bethesda, Md., since the 
beginning of 1979. 

Molar Absorbence of Cyanmethemaglobin From 
Blood of Different Animals by Rodkey FL, Robertson 
RF, and Kim CK. American Journal of Veterinary 
Research 40(6):887-888, 1979. 

LYB-7, A New B Cell Alloantigen Controlled by 
Genes Linked to the IGCH Locus by Subbarao B, 
Scher I, Ahmed A, Lieberman R, Paul WE, and 
Mosier DE. Journal of Immunology 122(6):2279- 
2285, 1979. 

Rhesus Monkey B Lymphocyte Surface Immuno- 
globulin: Analysis with a Fluorescence-Activated 
Cell Sorter by Finkelman FD and Scher I. Journal of 
Immunology' 122(5):1757 -mi, 1979. 

Cardiovascular and Metabolic Manifestations of 
Heat Stroke and Severe Heat Exhauston by Costrini 
AM, Uddin DE, Pitt HA, and Gustafson AB. Ameri- 
can Journal of Medicine 66:296-302, 1979. 

Immunological and Structural Properties of 
Human Monoclonal IGG Cyroglobulins by Abraham 
GN, Johnston SL, Podell DN, Welch EH, and Wistar 
R, Jr. Clinical and Experimental Immunology 36:63- 
70, 1979. 

Protective Activity of Antibodies to Exotoxin A 
and Lipopolysaccharide at the Onset of Pseudomo- 
nas Aeruginosa Septicemia in Man by Pollack M and 
Young LS. Journal of Clinical Investigation 63(2): 
276-286, 1979. 

Assessment of Protease (Elastase) as a Pseudamo- 
nas Aeruginosa Virulence Factor in Experimental 
Mouse Bum Infection by Pavlovskis OR and Wret- 
lind B. Infection and Immunity 24(1): 181-187, 1979. 

Production of Exotoxin A by Pseudomonas 
Aeruginosa in a Chemically Defined Medium by 
Debell RM. Infection and Immunity 24(1):132-138, 

Metabolism of Rickettsia Typhi: Speculations on 
Regulatory Mechanisms, in Microbiology — 1979 by 
Weiss E. American Society for Microbiology, Wash., 
D.C. pp 144-149, 1979. 

Drug Interference with the Trihydroxyindole 
Method for Free Catecholamines in Urine by Mell 
LD, Gustafson AB, and Dasler AR. NMRI Report, 
April 1979. 

Role of a Nonimmunoglobulin Cell Surface Deter- 
minant in the Activation of B Lymphocytes by 
Thymus-Independent Antigens by Subbarao B, 
Mond JJ, Mosier DE, Scher 1, Ahmed A, and Paul 
WE. Journal of Experimental Medicine 149:495- 
506, 1979. 

Extracorporeal Glass- Wool Filtration of Whole 
Blood Enhances Post-Ischemic Recovery of the 
Cortical Sensory Evoked Responses by Hailenbeck 
JM, Greenbaum LJ, Furlow TW, and Ruel TA. 
Stroke 10(2): 158-164, 1979. 

Saturable Metabolism and the Acute Toxicity of 
1,1-Dichloroethylene by Andersen ME, Jones RA, 
French JE, Jenkins LJ, Jr, and Gargas ML. 
Toxicology and Applied Pharmacology 47:385-393, 


The Use of Inhalation Techniques to Assess the 
Kinetic Constants of 1,1-Dichloroethylene Metabo- 
lism by Andersen ME, Jenkins LJ, Jr, Gargas ML, 
and Jones RA. Toxicology and Applied Pharmacol- 
ogy 47:395-409, 1979. 

Human and Mouse Specific T-Cell Helper Factors 
Assayed In Vivo and In Vitro: Implications for 
Human IR Genes by Woody JN, Ahmed A, Howie S, 
Zvaifler NJ, Hartzman R, Kantor F, Reese A, Strong 
M, Feldmann M. Transplantation Proceedings 11(1): 
382-388, 1979. 

MLC and CMC Reactivity and Specificity of 
Idiotype-Specific Lymphoid Cells Enriched for 
Histocompatibility (H-2) Antigens by Folks TM, 
Feldmann M, Ahmed A, Woody J, Ryan JJ, and Sell 
KW. Transplantation Proceedings ll(l):683-689, 

Volume 70, August 1979 


U.S. Navy Cold Weather Medicine 
Training Course: AChallenge Met 

LT Donald C. Arthur, MC, USN 

It's a beautiful winter's morning: 10° F and 12,500 feet 
elevation at Champion Pass in the majestic mountains 
of Colorado. We awaken in the warmth of our sleeping 
bags to discover that a few inches of newly fallen snow 
have blanketed our thin rainfly and hidden our gear 
outside. The sky is clear, the air crisp with no hint of the 
night storm which caused an avalanche within sight of 
our bivouac. We dress for another exciting day and 
begin preparing hot Ralston, fruit, fresh biscuits, and 
cocoa. A vibrant sense of excitement fills the air as it 
has each morning for the two-week Cold Weather Med- 
icine Training Course with the Colorado Outward 
Bound School (COBS) sponsored by the Naval Health 
Sciences Education and Training Command (NHSETC), 
Bethesda, Md. 

The Navy Medical Department has been challenged. 
Can we meet the needs of the Navy and Marine Corps 
on maneuvers in a high altitude, cold weather climate? 
Used to the tropical arena, our fighting men are un- 
accustomed to the vastly different demands of the cold 
and high altitude. Medical hazards await the unpre- 
pared, the untrained, and the careless. The Medical 
Department has been charged with preparing and 
training troops in the prevention, treatment, and 
evacuation of injuries and accidents indigenous to this 
environment. Such hazards include High Altitude Pul- 
monary Edema (HAPE) with its insidious and unpre- 
dictable onset, Acute Mountain Sickness (AMS), 

LT Arthur participated in the Cold Weather Training Course as an 
accredited part of his internship at NNMC, Bethesda, Md., and is 
presently attending flight surgeon training at the Naval Aerospace 
Medical Institute, Naval Air Station, Pensacola, Fla. 32508. 

hypothermia — the silent stalking killer, debilitating 
frostbite, snow blindness, psychologic stress, dehydra- 
tion, and on and on! 

The ill-prepared state of our troops was evidenced all 
too graphically by the 24 March 1979 New York Times 
headline; "Marines at 'War' in Norway's Arctic, Don't 
Cut." This referred to the annual NATO maneuvers 
that simulate the defense of northern Norway from So- 
viet attack. The Soviet naval base lies to the east of 
Murmansk. For the Soviet armadas posted at this, the 
world's largest naval base, to safely pass into the Arctic 
Ocean in time of war, northern Norway must be oc- 
cupied. We are pledged by treaty to assist the Nor- 
wegians in this totally unfamiliar climate. As the article 
illustrated in embarassing detail, we are unprepared. 
The article went on to describe that Marines flown from 
Camp Lejeune, N.C., and reservists from the Albany, 
N.Y. area were burdened with old, heavy, and inade- 
quate equipment. But their greatest burden was their 
lack of proper training in preventive measures and their 
lack of familiarity with the environment. The result was 
substantial and unnecessary morbidity. 

The Bureau of Medicine and Surgery and HSETC 
have accepted the challenge and developed an exciting 
training program for Medical, Nurse, and Medical 
Service Corps officers and hospital and fleet duty corps- 
men. The program begins with a three-day seminar 
introducing the participants to the theories of survival 
in the cold (see Table) with emphasis on prevention — 
prevention of accidents as well as disease. Then the fun 
begins — and the hard work. The next 10 days are spent 
with the Colorado Outward Bound School basecamped 
at Leadville, Colo., the highest inhabited settlement in 
North America at 10,000 feet above sea level. Here 
expert civilian instructors, all experienced ski patrollers 


U.S. Navy Medicine 

Pre-Cobs Course Preparatory Seminar Outline 

I. General Objectives 

A. Experiences and needs for cold weather medi- 
cine training in the military today 

B. Logistical considerations 

C. Medical considerations 

II. Medical Aspects 

A. Cold physiology and adaptation mechanisms 

B. Disorders peculiar to the cold and altitude 

1. High Altitude Pulmonary Edema (HAPE) 

2. Acute and Chronic Mountain Sickness (AMS 

3. Hypothermia 

4. Frostbite 

5. Snow blindness 

6. Epidermal/dermal water injuries 

7. Psychologic stress 

8. Nutrition and hydration 

C. Principles of medical management 

D. Problems of medical management in the cold 
and altitude 

E. Principles of preventive medicine and heat reg- 

1. Clean, Dry, Wool 

2. Fabric comparisons 

3. Layer system 

F. Hygiene and Sanitation 

III. The Environment 

A. Weather patterns, thermal layers, cloud forma- 
tions and their meaning, anatomy of a weather 
front — how to know what to expect 

B. Physics and mechanics of snow types and depo- 
sition patterns; changes of aging, wind and sun 
exposure, and compaction 

C. Mechanics of avalanche formation with focus 
on recognition of potential sites 

D. Map and compass use with emphasis on guid- 
ance by topography and safe route selection 

IV. Search and Rescue Techniques 

A. Avalanche rescue techniques 

B. Basic First aid and stabilization with emphasis 
on the team approach 

C. Evacuation techniques 

V. Principles of the Bivouac 

A. Site selection 

B, Organization of the site 

C, Division of labor 

D. Sanitary and ecologic considerations 

VI. Diet Planning 

and wilderness travelers, teach the practical aspects of 
survival in the high altitude cold. From the first day, 
you don cross country skis and are out in the snow 
learning to be a part of the environment. You are taught 
how to keep warm, treat and evacuate the incapaci- 
tated, recognize avalanche potentials, rescue avalanche 
victims, set up a bivouac, and cook tasty as well as 
nutritious meals. 

The next three days comprise the "basic" expedition 
where the emphasis is on the application and perfection 
of the tasks you have only simulated thus far. You learn 
to camp and survive in the grand wilderness; but the 
most important lessons are of respect and confidence — 
respect for an unforgiving environment that offers no 
support and confidence in yourself to overcome it. You 
recognize that nature is never really conquered. She 
merely allows you to survive as long as you're cautious, 
knowledgeable, and respectful. As your caution 
becomes automatic, your respect and appreciation of 
the power and beauty about you grows. It is both 
humbling and exulting. You feel as if you have been 
taken within nature's womb and made a part of her. 
You are no longer an intruder. You learn to take full 
advantage of the environment by building igloos and 
snow caves where you can be warm at a constant 32° F 
while the sub-zero weather is harsh outside. It snows 
and you learn yet another lesson — kitchenware should 
not be left uncovered and unmarked lest you search and 
search in the early light of morning. 

Returning to basecamp, you're now confident that 
you can not only survive in the cold but enjoy every 
minute of it! After a triumphant "basic" expedition, 
you're now ready for the "Alpine" expedition, This 
time, the planning, route, pace, and destination is 
your responsibility, no longer the instructors' as on 
the "basic." This is the test you've been preparing 
for. The group is divided into subgroups according to 
general physical conditioning and skiing ability. The 
stronger choose the higher and longer routes while the 
others select less demanding, yet equally rewarding 
paths. Early the next morning the groups set out to test 
their new skills on a five-day excursion over the scenic 
and historic Colorado Rockies. The beauty of the tower- 
ing 14,000-foot peaks contrasted with the pathos and 
struggle that we felt must have accompanied those who 
worked the 19th century iron mines in this remote ore- 
rich land. 

Our group of six (four men and two women) took the 
long and high route over scenic Champion Pass, the 
19th century focus of iron mining in Colorado. We left 
the basecamp on skis, carrying all the necessities for 
survival on our backs, and journeyed nine miles 
through the San Isabel National Forest. Our path took 

Volume 70, August 1979 


Troops on skis with full packs (center) moving in open mountain ranges at 11.000 feet near Champion Pass, Colo. 

us along the frozen Halfmoon Creek between suc- 
cessive 12,000 and 13,000-foot peaks with their ava- 
lanche trails looming above us. Toward dusk we chal- 
lenged a steep incline and came upon the first rem- 
nants of the courageous men who lived year-round 
in this hostile environment. Their 100-year-old log 
cabin, weatherbeaten with wind howling through the 
cracks and beneath the poorly fitting door, was still a 
welcome sight in this uncivilized land. The meager 
heat emitted by an ancient wood-burning stove warmed 
our bodies and our hearts as we felt ourselves drift into 
the past. We felt a respect for and an identity with our 
predecessors and a special sense of camaraderie with 
each other and a sense of accomplishing a common goal 
yet only partially achieved. We enjoyed a comfortable 
night in what seemed like heaven in the midst of a 

In the following days, we traveled steadily up to the 
high country passing the old Prospect Mine and on to 
Champion Mill at 12,000 feet. We camped within sight 
of the 12,500-foot pass we were to cross the next day. 
Champion Mill, one of the oldest iron mills in Colorado, 
received its ore by giant tramway connecting it to the 
Champion Mine, a mile away and a thousand feet 
higher in elevation. The deserted mill revealed the 
skeletons of a foundry which once converted iron ore to 
pellets that were transported by mule cart to Leadville 
15 miles away along the same path we had just 

Onward we went over Champion Pass where we had 
planned to drop our packs and ascend the peak to 
13,700 feet, returning to collect our gear and continue. 
The unpredictable mountain weather had other plans 
for us. What was a clear and inviting sky in the early 


U.S. Navy Medicine 

morning had turned to a blinding blizzard by noon with 
30 mph winds. We were in avalanche country and knew 
that the danger of new slides was greatest during and 
just after a storm, especially if the snow was the wet 
and heavy type as was falling. The journey up to the 
pass was steep and slow; our feet were becoming cold 
and still in the leather boots. A cardinal rule in the 
mountains in that you must not allow your feet to get 
cold; this is the first sign of trouble. Now was the time 
to practice the lessons learned in the comfort of the 
basecamp. Those with cold feet paired off, removed 
their boots and socks and placed their feet under each 
others' arms to warm them. We all felt responsible for 
each others' survival; indeed we were no longer six in- 
dividuals. Our energies and resources had been molded 
into one. After a half-hour revival, we continued 
our trek until at last we reached the pass. Visibility was 
a mere 100 feet and the wind howled, whipping the cold 
air and snow about us. We quickly abandoned our plan 
to ascend the peak and turned our attention to proceed- 
ing to safety below the tree line as soon as possible. 

We stood on a wind-swept pass at 12,500 feet in a 
white-out blizzard facing a long and difficult ski down to 
safety along a path between successive avalanche 
trails. Our feet were again chilling and we were tired 
from the steep ascent to the pass. It was at this moment 
that we realized that if an accident were going to 
happen, it would be now — the worst possible time. We 
sharpened our senses to prevent it and recalled the 

Champion Mill — the remains of a once busy iron ore mill at 
12,000 feet in the Colorado Rockies. 

lessons of safety and evacuation of victims under such 
harsh conditions. We then cautiously made our way to 
safety in the Lackawana Gulch. 

Our last night was spent in proud reflection of the 
challenge we had met as we enjoyed dinner around a 
blazing fire. Early the next morning we joined the other 
group and shared adventures. RADM [Stephen] 
Barchet, MC, USN, from HSETC joined us at basecamp 
that evening to learn of our impressions of the course 
and to share our enthusiasm for the program. It had 
taught us the fundamentals of cold weather survival 
and principles of preventive medicine and allowed us to 
test them in the field. In addition we learned to cross 
country ski and survive in the rough mountain winter. 
But most importantly, it had given us confidence that 
we could use our knowledge, transfer it to others, and 
apply those newly found skills and confidence within 
the special world of Navy medicine. It was a mission 

The goal of the Cold Weather Medicine Training 
Course is to provide personnel specific training to 
give medical support in cold weather, to provide train- 
ing and support to the Marines and our ships in Arctic 
waters, and to instruct others in these vital skills. These 
select people will provide evidence that the members of 
the Medical Department are capable of living with the 
troops in the cold, helping prevent injuries and attend- 
ing to those that do occur. The troops' confidence in us 
will go far in making their job easier. 

Selection priority for participants will be given first to 
those who are most apt to move with their troops and 
those in a position to instruct others. Plans are already 
under way for next year. Four more courses containing 
36 participants each will be offered. Training will be for 
both individuals and preselected teams who would train 
together and be able to move together as an integrated 
functional medical unit including surgeons, internists, 
nurses, corpsmen, and Medical Service Corps officers. 

Can you go? YES! The only requirement is that you 
possess a spirit of excitement and adventure. Partici- 
pants have ranged from 22-year-old Seals to 40-year-old 
FMSS Chiefs to 5' 2", 100-pound women. All carried 
their 60-pound packs from start to finish and loved it. 
The air is thin and the work is difficult, so good physical 
conditioning is essential and smoking is a decided 

For further information, contact either: RADM 
Almon C. Wilson, MC, USN, Commanding Officer or 
CAPT B. Dutton, MC, USN, Head, Department of 
Operational Medicine, Naval Health Sciences Educa- 
tion and Training Command, National Naval Medical 
Center, Bethesda, Md. 20014. Telephone Autovon 295- 
0023 or Commercial (202) 295-0023. 

Volume 70, August 1979 


Continuing Education in the Nurse Corps 

CDR F.C. McKown, NC, USN 

The overall authority and responsibility for education 
and training in the Navy Medical Department resides in 
the Naval Health Sciences Education and Training 
Command (HSETC), Bethesda, Md. HSETC, under the 
immediate direction of the Chief, Bureau of Medicine 
and Surgery: 

• Implements policy and exercises control, adminis- 
tration, and management of health sciences education 
and clinical investigative training programs of the De- 
partment of the Navy; 

• Develops plans, objectives, priorities, organiza- 
tion, procedures, and standards to meet education and 
training requirements; 

• Establishes, evaluates, and maintains optimal 
health sciences education and training programs that 
will insure maximal responsiveness to the operational 
and professional needs of the Naval services; and 

• Provides budgetary support for the training activi- 
ties and programs of the Medical Department of the 

Within HSETC, the Director of Nurse Corps Pro- 
grams acts under the policy guidance and direction of 
the Commanding Officer to fulfill the responsibilities 
listed above for the education and training of Nurse 
Corps officers, maintaining close liaison with the 
Nursing Division, Bureau of Medicine and Surgery. 
Currently, Nurse Corps education programs include 
full-time duty under instruction, part-time outservice 
training, and continuing education. 

Fall-Time Duty Under Instruction 

Nurse Corps officers interested in requesting full- 
time duty under instruction leading to a baccalaureate 
or master's degree and those officers requesting the 
Primary Care Practitioner Program at NRMC San Diego 

CDR McKown is assistant director. Nurse Corps Programs, Navai 
Health Sciences Education and Training Command, Bethesda, Md. 

should consult the BUMEDINST 1520.14 series. This 
instruction specifies the programs available and the 
application procedure. Applications for full-time duty 
under instruction will not be accepted until the individ- 
ual is within 18 months of their PRD. The next Profes- 
sional Advisory Board meets on 15 Oct 1979 and all ap- 
plications must be in HSETC by 1 Sept 1979. Starting in 
May 1980, the board will meet on an annual basis, with 
applications required by 15 March. 

Officers selected for duty under instruction will apply 
at an NLN-accredited university of their choice, how- 
ever, cross-country travel will not routinely be autho- 
rized and PRD's cannot be shortened to coincide with 
school entrance dates. It is important to remember 
these restrictions when selecting a school. Prior to 
making application for duty under instruction, the cur- 
rent list of NLN-accredited programs should be con- 
sulted. Nursing education, nursing administration, 
research, a clinical specialty, or a combined clinical and 
functional component are all acceptable majors for 
graduate education. Applicants should review graduate 
school entrance requirements prior to applying for 
school to insure eligibility for admission and satisfac- 
tion of prerequisites. 

As a prerequisite for the Nurse Anesthesia Program, 
applicants must have one year of college-level sciences, 
to include one semester of chemistry with a demon- 
strated aptitude for science and mathematics. This pro- 
gram, conducted at the George Washington University, 
Washington, D.C., and the Naval School of Health 
Sciences, Bethesda, Md., is a one-year didactic course 
followed by a one-year clinical phase at Naval Regional 
Medical Center, San Diego or Portsmouth. 

Nurses applying for the Navy's one-year Primary 
Care Practitioner Certificate Program should indicate in 
the application their preference for a specialty of 
pediatrics, family care, or Ob/Gyn. 

Part-time Outservice Training 

Nurse Corps officers interested in attending courses 
related to areas of Medical Department responsibility 
should consult the BUMEDINST 1500.7 series. This 


U.S. Navy Medicine 

instruction specifies the eligibility, obligated service 
requirements, and the application procedures. Those 
interested in full-time duty under instruction can fre- 
quently satisfy prerequisites and obtain numerous 
transferrable credits through this program. 

Continuing Education 

With the rapid increase in technology, advances in 
medical science and changing health care concepts, 
continuing education for Nurse Corps officers is a vital 
component of quality health care. The BUMEDINST 
4651.1 series delineates BUMED policy in support of 
continuing education. Funding for continuing education 
is the responsibility of local commanding officers. 
However, HSETC has limited funds available for at- 
tendance at those civilian and military short courses, 
workshops, and seminars which award continuing edu- 
cation credit. These funds must be used judiciously. 
They do not include conferences, conventions, insti- 
tutes, or lengthy job-training courses. Requests for 
funding should arrive in HSETC four to six week before 
the course and be accompanied by a descriptive flyer or 
brochure. Normally, cross-country travel will not be 
authorized for the courses. Approval cannot be granted 
for requests arriving at HSETC after the starting date 
of the program, 

HSETC annually co-sponsors, with NRMC's, courses 
particularly relevant to the needs of Navy nurses. It is 
anticipated that the FY80 Nurse Corps education calen- 
dar will include: 

• a nursing symposium, in conjunction with the 
AMSUS Convention in San Diego 

• The Perinatal Period (NRMC, Portsmouth) 

• Physical Assessment of the Adult (two courses at 
NRMC, Corpus Christi) 

• Middle Management (NSHS, Bethesda) 

• Senior Management (NSHS, Bethesda) 

• Character Disorders (NRMC, Oakland) 

• Education Workshop (NRMC, Oakland) 

• Alcoholism and Food Abuse (NRMC, Long Beach) 

The completed calendar will be sent to all commands in 
the near future. 

In 1977, HSETC received a four-year accreditation by 
the Northeast Regional Accrediting Committee of the 
American Nurses' Association as a Provider and 
Approver of Continuing Education. A pilot study is 
currently underway whereby HSETC Provider status 
may be given to certain Naval Regional Medical Cen- 
ters in recognition of the extremely high quality educa- 
tion courses being developed locally, and to reduce the 
administrative burden of approving these courses for 
continuing education credit. 

It is not possible to cover every aspect of nursing 
education news in an article. Each Nurse Corps officer, 
after reviewing the BUMEDINST pertaining to their 
area of interest, should contact the Director, Nursing 
Service, the Nursing Educational office or HSETC for 
further information. We are here to serve you and en- 
courage your questions, ideas, and suggestions. 

Quantico Relief Force Practices Medicine 

On 17 July 1979, VADM Willard 
P. Arentzen (MC), led a contin- 
gent of 30 physicians from 
NNMC and BUMED to Quantico, 
Va., to help with a massive medi- 
cal screening program for Marine 
Corps officer candidates. This 
was the third of three physical 
exam days this summer at Quan- 
tico and the third attended by the 

Washington area physicians. 
Overall, 2,674 candidates were 
examined, 950 on the 17th alone. 
The long day began at 0600 at 
the Mann Hall branch clinic, 
where the candidates were given 
dental exams. The physicals and 
immunizations followed at the 
hospital. The last candidate was 
processed by 1545. 

"It was a very hectic day for 
the physicians taking part," said 
CDR James Erie (MSC), Com- 
manding Officer of NRMC Quan- 
tico. Yet the doctors who partici- 
pated found it a welcome break 
from the routine duties most of 
them are accustomed to. All en- 
joyed the opportunity to perform 
additional direct patient care. 

Volume 70, August 1979 



Intraoral Removal of a Large 
Submandibular Gland Sialolith 

CDR Michael T. Ridley, DC, USN LCDR R. Sidney Jones, DC, USN LT G.B. Ingraham III, DC, USNR 

The intraoral removal of a large submandibular duct 
sialolith is the subject of this report. It is of further in- 
terest because of its size, shape, and duration. 

A 30-year-old Caucasion male was referred to the 
Naval Regional Medical Center, Charleston, S.C. on 13 
April 1978, for treatment of pain and swelling in the 
right submandibular area and floor of mouth, and with 
some mild degree of dysphagia. 

Past medical records revealed a long history, at least 
20 years, of pain and slight swelling during and after 
eating; however, the swelling and pain usually 
subsided in one to two hours and was not a constant 
finding after meals. The patient sought no treatment 
for this as he attributed it to the hot spicy foods fre- 
quently served in his home. Four days prior to examina- 
tion, he experienced pain of a longer duration and 
marked swelling that failed to subside. Exudate from 
the duct on the right side had only been noted one time 
during the entire history of pain and swelling, that 
being four months prior to examination. The remainder 
of the medical history was noncontributory to the chief 

Physical examination revealed a well-developed, 
well-nourished Caucasian male in no acute distress. 
The right submandibular gland was moderately swollen 
and painful to palpation. Examination of the oral cavity 
revealed dentition in a good state of health . Soft tissues 
of the oral mucosa were unremarkable except for the 
mucosa of the right floor which was moderately ele- 
vated, slightly erythematous and tender to palpation. 
Bimanual intra and extraoral examination of the sub- 

CDR Ridley is chief of the Dental Service, NRMC, Charleston, S.C. 

LCDR Jones is an oral surgeon at NRMC Charleston. 

LT Ingraham practices general dentistry and is also on the NRMC 
Charleston staff. 

mandibular glands and Wharton's ducts revealed 
normal structures on the left side while the right was 
moderately swollen, indurated, and painful to palpa- 
tion. The right Wharton's duct was occluded as evi- 
denced by failure to express fluid from the duct. 
Further examination revealed an indurated mass ap- 
proximately 2 cm from the orifice along the course of 
the right Wharton's duct. Panorex and occlusal radio- 
graphs comfirmed the presence of a rather large sialo- 
lith in the right Wharton's duct approximately 2 cm 
from the orifice (Figure 1). 


On 14 April 1978, the patient was prepared for intra- 
oral removal of the sialolith. Using local anesthesia 
supplemented with intravenous sedation, the right 
submandibular duct was dilated with progressively 
larger lacrimal probes. The operator then made an inci- 
sion over the probe from the orifice to a point approxi- 
mately 2 cm proximal to the orifice of the submandibu- 
lar duct. Using blunt dissection, the sialolith was 
visualized and removed in one piece with Adson-Brown 
forceps (Figure 2). Hemostasis was easily obtained with 
pressure and the wound left open to granulate in sec- 
ondarily. Copious amounts of normal saline was used to 
irrigate the duct and remove any residue of the sialo- 

Three weeks postoperatively, the operative site had 
essentially healed and the patient experienced no dis- 
comfort or swelling. The right Wharton's duct was 
patent, and copious, clear saliva could be milked from 
the duct. The only remarkable feature of the operative 
site was an elongated orifice of approximately 3mm 
where secondary healing of the duct was still progress- 

The sialolith was whitish yellow in color, weighed 1.6 


U.S. Navy Medicine 

FIGURE I. Panorex showing sialolith. 

^__— yri 1 1 g 1 1 1 1 1 1 1 II 1 1 1 II II 1 1 1| 1 1 ilT 

I (15) 2 3 

FIGURE 3. The sialolith measured 27 mm x 11 mm. 

grams, and measured approximately 27 mm x 11 mm, 
with an essentially eliptical cross-section to the long 
axis. It tapered off in the duct and was very similar in 
shape to a large canine tooth (Figure 3). 


Thoma states that salivary sialoliths are not uncom- 
mon, having been found in one percent of the patients 
coming to autopsy. Submandibular glands and ducts in 
fact account for 92 percent of all salivary gland sialo- 
liths. (1) Nor are large salivary gland sialoliths excep- 
tional findings. Many weigh 5 to 15 grams and several 
larger ones have been reported. (2) Carr, in 1965, re- 
ported a stone removed from a Wharton's duct of 
similar size and shape to the one reported herein. (J) 
The interesting point in this case is not only the size and 
shape of the sialolith, but also the duration of the 
symptoms before the patient sought treatment. The 
average patient usually has had symptoms of sialo- 
lithiasis of the submandibular gland for a year and a 

half before seeking attention! The patient in this case 
had symptoms since childhood, but had sought treat- 
ment only when the condition became acute. It is also 
surprising that this sialolith had never been diagnosed 
during any of the patient's induction, annual, or trian- 
nual physical examinations; he had been in the armed 
services for 10 years. This fact illustrates the impor- 
tance of palpating biannually the structures of the floor 
of the mouth, parotid glands and ducts, and subman- 
dibular areas, as well as the cervical and mental lymph 
nodes. The procedure should be part of every 
clinician's routine head and neck examination. 


1. Thoma's Oral Pathology, ed 6, St. Louis, CV Mosby Co, 1970. 

2. Brusati R, Fiamminghi L: Large Calculus of the Submandibu- 
lar Gland: Report of Case. J Oral Surg 31:710, Sept 1973. 

3. Carr SJ: Sialolith of Unusual Size and Configuration: Report of 
a Case. Oral Surg 20:709, Dec 1965. 

—Photos by HM2 Martin A. Gurnik 

Volume 70, August 1979 


Nutritional Support: The Use 
of Assessment Principles and a 
Nutritional Preparations Formulary 

LT Steven R. Lamar, MSC, USN Laurie S. Hursig, RD 

Comprehensive nutritional support is a factor of major 
importance in the treatment, palliation, and prevention 
of disease. It is the physician's obligation to recognize 
that significant clinical relationships exist between a 
patient's nutritional status and the eventual outcome of 
the disease process. (/) Therefore, the development of 
an appropriate treatment regimen which includes 
proper nutritional management is requisite to providing 
total patient care. Recent advances in the clinical ap- 
plication of nutritional assessment techniques and the 
current availability of numerous adult nutritional 
formulas afford the physician an opportunity to more 
effectively manage this nutritional care responsibility. 
The purpose of this paper is to acquaint the clinician 
with the basic concepts of nutritional assessment and to 
introduce a Nutritional Preparations Formulary. (2) This 
formulary has been developed to assist the physician in 
the prescription of formula diets most compatible with 
patients' clinical problems and nutritional require- 

Nutritional Status Evaluation 

In recognition of this nutritional management re- 
sponsibility, today's clinician now places considerable 
emphasis on the establishment and maintenance of an 
optimal nutritional status in order to minimize the com- 
plicating effects of malnutrition on the patient's 
hospital course. Increased morbidity and mortality, 

LT Lamar is presently attending Case Western Reserve University, 
Cleveland, Ohio. Miss Hursig is a clinical dietition at the Food Man- 
agement Service, Naval Regional Medical Center, Camp Pendleton. 
Calif. 92055. 

The authors wish to acknowledge the support of LCDR John C. 
Gerhard, MSC, USN, chief, Food Management Service, in the prepa- 
ration of this article and thank HN John T. Wood, USN, whose photo- 
graphic skills contributed directly to the clarity of manuscript figures 
and tables. 

depressed cell-mediated immunity, delayed wound- 
healing, and increased susceptibility to infection are all 
potential consequences of inadequate or ineffective 
nutritional management. (J) 

Positive nutritional support, responsive to specific 
nutritional and metabolic requirements, must be pre- 
ceded by a thorough understanding of the patient's 
present nutritional status. A useful nutritional assess- 
ment protocol provides the clinician with the means of 
identifying the presence of nutritional deficiencies and 
directs appropriate corrective nutritional therapy. The 
basic components of the typical nutritional assessment 

methodology are the patient's history (e.g. medical, 
surgical, social, psychological, and diet), anthropo- 
metry, and specific nutrition-related laboratory 
tests(4) Traditional nutritional assessment methods 
require the development of a nutritional/metabolic 
profile, which may include the following parameters: (5) 

• Height 

• Weight 

• Basal energy expenditure in kilocalories per day 

• Actual weight as a percentage of ideal weight 

• Actual triceps skinfold thickness as a percentage of 
the standard value 

• Actual mid-upper arm muscle circumference as a 
percentage of the standard value 

• Creatinine/height index 

• Serum albumin level 

• Serum transferrin level or total iron-binding capac- 

• Total lymphocyte count 

• Measure of cell-mediated immunity (delayed 
hypersensitivity reaction) 

• Nitrogen balance 

• Apparent net protein utilization 


U.S. Navy Medicine 

TABLE 1. Nutritional Assessment Summary 

Patient's Name: 

Nursing Unit/Room No. : 


Attending Physician: 

Diagnosis : 

Height : 

Admission Weight: 

Present Weight: 

Desirable Weight: 

Standard Parameters 

Patient Values 


90% Std. 


60-90% Std. 


60% Sfcd, 



Kg cm 

Triceps Skin-fold (TSF) 


Mid-Arm Circumference (MAC) 


Mid-Arm Muscle Circumference (MftMC) 
MAMC(cm)=MflClcm)-{3.14 X TSF (cm)) 


Total Lyinphocyte Count 


Serum Albumin 


Total Iron Binding Capacity (TIBC) 



Serum transferrin (0.8 X TIBC)-43 

mg/ 100ml 

Urinary Creatinine 


Creatinine Height Index (CHI) 

Actual Urinary Creatinine „ 10Q 


"""• Ideal Urinary Creatinine " '" 

* Not Depleted ** Moderately Depleted *** Severely Depleted 




g/100 ml 

Cellular Immunity: 
{ ) Pos. ( ) Neg. 

Dietary Intake Evaluation: Calories. 

Cal/24 hr 



Protein intake 

Protein Status: Nitrogen Balance = (UUN + 4) 


( ) Pos. ( ) Neg. 

Volume 70, August 1979 


FIGURE 1. Nutritional Assessment Decision Tree 

Proceed with 

treatment of 



Upon Admission: 

Check if any of the following 

are present: 

* Recent weight loss > 10 lbs. 

* T-lynphocyte count <, 1500mn3 

* Illness lasting > 3 weeks 

* Serum albumin < 3.5g% 

* Recent surgery 


Delay elective 
surgery and 
radiation therapy 

* Obtain weight for height standard 

* Obtain anthropometric measurements 

* Administer skin tests 

Monitor nitrogen 

balance and serum 

albumin levels 


Are results < 85% of standard? 



Are any of the following present? 

* Creatinine/height index <, 60% of standard 

* Negative skin tests 

* Serum transferrin < 150mg 


Withhold elective therapy until 
significant nutritional repletion 
is acconplished 

Appropriate enteral nutritional 
support is indicated 

Select diet and/or nutritional 
preparation based on patient's 
nutritional requirements , 
clinical problems, food intol- 
erances, etc. 



Determine route of administering 
nutritional support 

Is G.I. tract functional? 


Consider central or peripheral 
vein hyperalimentation 

Contact Pharmacy Service 

Is appetite present? 




* Traditional feeding methods (regular foods) 
plus appropriate supplemental formula 

* TOtal nutritional support with "defined 
formula diet" (oral) 

Contact Food Management Service 

* Total nutritional support with 
tube feeding formula 

* Total enteral hyperalimentation 
(via nasogastric tube) 

Contact Pood Management Service 

U.S. Navy Medicine 

• Weight change as percent of usual weight {with 

• Caloric intake as a multiple of basal energy ex- 

• Body surface area in square meters 

The nutritional assessment process usually involves 
assembling data in tabular form to simplify evaluation. 
Table 1 illustrates an example of a nutritional /meta- 
bolic data summary form. Patients showing laboratory/ 
anthropometric values within 90 percent of standard 
parameters are generally considered to demonstrate an 
acceptable nutritional status. A 60-90 percent deviation 
from standard values suggests moderate nutritional 
depletion; less than 60 percent of standard indicates 
severe depletion. (J) Much of this information, such as 
height, weight, and serum albumin level, is collected 
routinely as a part of the general medical workup. 
Other data, such as anthropometric measurements, are 
easily obtained in the clinical setting. However, factors 
that may indicate current nutritional intake status, such 
as protein intake required for the calculation of nitrogen 
balance and net protein utilization, may not be readily 
available without efficient nutrient data processing 
systems. (6) Once these data are assembled and evalu- 
ated, decisions concerning nutritional support require- 
ments can best be made by logically progressing 
through an algorithmic Nutritional Assessment Deci- 
sion Tree as shown in Figure 1.(7) 

Methods of Achieving Optimal 
Nutritional Status 

In many cases an optimal nutritional status is 
achieved by means of traditional feeding methods (i.e., 
regular food consumed by mouth). This typically in- 
volves the consumption of three nutritionally balanced 
meals per day. However, in order to meet the numerous 
and varied nutritional needs resulting from disease or 
injury, a patient's meals may require modification in 
one or more basic ways: nutrient content, food texture 
or consistency, and ingredient composition. These 
types of dietary modifications generally satisfy the 
nutritional needs of most patients. Nevertheless, in 
some instances an adequate consumption of oral food is 
not possible due to extreme dietary requirements, 
physical impediments, or psychological problems. 
Therefore, when these traditional patient feeding 
methods are not effective, the use of liquid nutritional 
preparations (i.e., defined formula diets) provides an 
important alternative in achieving and maintaining 
optimal nutritional status. 

Severe dietary restrictions are often imposed in order 

to accommodate altered metabolic states. Patients with 
major burns have significantly increased energy, 
protein, and vitamin/ mineral requirements but may be 
unable to consume the large portions of food necessary 
to satisfy these requirements. (8) Patients with hepatic 
encephalopathy require minimal protein but adequate 
calories. Acute renal failure may necessitate the institu- 
tion of protein, electrolyte, and fluid restriction. How- 
ever, all patients, regardless of the complexity of the 
dietary restrictions indicated by their disease process, 
require an intake capable of satisfying basic nutritional 
needs. Providing these modifications through the use of 
regular foods may not be realistically achievable with- 
out severely affecting the palatability and nutritional 
adequacy of the diet. On the other hand, the select 
administration of an appropriate nutritional preparation 
(i.e., defined formula diet) often compensates for these 
nutritional inadequacies without compromising the 
prescribed therapeutic restrictions. 

Physical impediments and psychological problems 
may also preclude the consumption of nutritionally 
complete regular meals. The use of liquid formulas is 
frequently indicated for patients with impaired mastica- 
tion, mandibular fractures, or anorexia secondary to 
disease processes or depression. When the ability to 
ingest even the liquid formula by mouth is impaired 
(e.g., in the comatose patient or in the absence of the 
swallowing reflex), the administration of defined 
formula diets via nasogastric tube may very well be the 
only means of achieving satisfactory enteral nutritional 
support. Additional clinical conditions that may 
indicate the use of defined formula diets are listed in 
Table 2.(2) 

Nutritional Preparations Availability and 
Product Information 

A large number of nutritional preparations (i.e., de- 
fined formula diets), significantly different in composi- 
tion, nutrient content, and intended route of adminis- 
tration, are now available commercially. Some formulas 
have been developed for highly specific clinical condi- 
tions, whereas other formulas are multipurpose and 
have a variety of potential clinical applications. The 
physician, attempting to select the most appropriate 
formula, may feel overwhelmed by the large number 
and wide variety of formulas from which to choose. 
Further confusion concerning formula selection may 
also be caused by the lack of readily available product 
data and by the frequent paucity of these data. To assist 
the physician and nutritionist in the prescription of 
formula diets most compatible with patient's clinical 
problems and nutritional requirements, a manual 

Volume 70, August 1979 


FIGURE 2. Nutritional Preparations Data Sheet 


Available frun rood 
Management Service: 

MuitipuKpeiC, Hu-t'u.tie nail ilif Ccmpte-te 
product type: fc * jnuai ^ Tetu /Supplemental Uic 

Container /Packaging Information: 
Available in i r 12, and 32 il-oz cam [liquid]. 
Packed ll-&ez/12ez cani/case; 6-32oz cans/case. 



nntmrr rr.MPr.STT inn- lntac ' t p *<*e*" ton**i***9 *^fc, PlottAJI ItotAttA- 


Protein Source: 

Concentrated Skim itilk 

to + Ca Caieinate 

Soy Pxotein Hotate 

Gluten Fict 

Fat Source: 

Soy OH 

P:S Ratio - 3.0:1.0 

Carbohydrate Source: 


Coin Sytup Solid* 

X Cal. from Protein: 

X Cal. from Fat: 

X Cal. from Carbohydrate: 



Per: <2 il'OZ 

il Caul 

Per 1000 ml 
{Standard Dilution) 

Calories Kcal 



Protein g 


60. 3 

Fat g 


23. 1 

Cholesterol mg 



Carbohydrate g 


137. i 

Lactose g 



COST: lOOOml/gtn Pro. 
(Standard Dilution) 

(Standard Dilution) 

1 Cal/mt 



[Standard Dilution) 

625 m£V 


A(5*c-i opening, product ihoald be 
covered and xedrlaeAated Ifa not 
Med immediately. Unu&ed ponticni 
ihvutd be diicakded afiten 24 hi. 

VOLUME at Standard Dilution Required 
to Provide 100% of the RDA for all 
known essential nutrients: 


*A defined nutritional preparation 


U.S. Navy Medicine 

FIGURE 3. Sustacal Liquid 


Per: 12 fl-oz (1 Can) 

Per 1000 ml 

(Standard Dilution) 













Vitamin A IU 
Vitamin D IU 
Vitamin E IU 
Vitamin C mg 
Folic Acid mg 
Thiamin (Vit. Bl) mg 
Riboflavin (Vit. B2) mg 
Niacin mg 
Vitamin B6 mg 
Vitamin B12 meg 
Biotin mg 
Pantothenic Acid mg 





Per: 12 fl-oz (1 Can) 

Per 1000 ml 
(Standard Dilution) 

Calcium mg 
Phosphorus mg 
Iodine meg 
Iron mg 
Magnesium mg 
Copper mg 
Zinc mg 
Sodium mg 
Potassium mg 
Chloride mg 
Manganese mg 

133 (14.5 mEq) 
740 (18.9 mEq) 

926 (40.3 mEq) 
2055 (52.7 mEq) 

Volume 70. August 1979 


TABLE 2. Nutritional Preparations: 
Indications for Use 

The following clinical conditions frequently neces- 
sitate the use of "Defined Formula Diets" to im- 
prove and maintain nutritional status: 


inflammatory bowel disease 

Malabsorption syndromes 


Chemotherapeutic and radiation enteropathy 

Pancreatic dysfunction 

Partial bowel obstruction or esophageal stricture 

G.I. tract not challenged by food for extended period 


Cerebral vascular accident 
Semiconsciousness or coma 
Traumatic nerve damage 
Palsies or paralysis 

Mvpc rmetabolic 
Severe trauma 
Major bums 
Major sepsis 


Oral surgery 

Pre and post surgical nutritional management 
Plastic surgery 

Radical surgery of alimentary tract, neck, or upper res- 
piratory system 


Impaired mastication 
Severe injury; large wound surfaces 
Convalescence following severe illness or injury 
Multiple fractures: mandibular fractures 
Extensive blood loss or tissue damage 
Debilitation due to senility or terminal disease 


Anorexia; cachexia 
Severe depression 
Food prejudice 
Mental retardation 

Inborn Errors of Metabolism 

Acute and Chronic Renal Failure/Acute Liver Failure 

Advanced or Metastatic Carcinoma 


Adjunct to or in transition from IV hyperalimentation 

Nonallergenic food source 

Toilet management problems; fecal incontinence 

Source: "Nutritional Preparations Formulary. "Q) 

TABLE 3. Products Included in Nutritional 

Preparations Formulary 


Low Sodium Provida 

Precision LR 
















Ensure Plus 






Formula 2 




Precision HN 



Precision Isotonic 

Vivonex HN 

providing detailed product information has been 
developed. (2) This manual, entitled Nutritional Prepa- 
rations Formulary, provides complete, up-to-date 
product data relevant to the nutritional management 
responsibilities of the clinician.* 

The product information and nutrient data contained 
in the Nutritional Preparations Formulary are orga- 
nized in four main sections: Indications for Use, 
Product Listing/ Product Type Definition, Data Com- 
parison, individual formula Data Sheets. The manual 
contains a Nutritional Assessment Decision Tree 
(Figure 1) which is intended to be used interactively 
with the diagnoses listed in Table 2 in order to best 
determine the need for nutritional support by formula 
administration. There are 33 nutritional preparations 
(i.e., defined formula diets) addressed in this formulary 
as listed in Table 3. The Nutritional Preparations Data 
Comparison chart, reproduced in an abbreviated form 
in Table 4, summarizes selected data descriptive of 
these 33 formulas and compares individual formula 
characteristics to facilitate product selection. The bulk 
of the Nutritional Preparations Formulary consists of 
Nutritional Preparations Data Sheets, which provide 
more comprehensive, detailed information on an indi- 
vidual formula basis. Figures 2 and 3 represent sample 
Nutritional Preparations Data Sheets. 

The Nutritional Preparations Formulary developed 
for use at the Naval Regional Medical Center, Camp 
Pendleton, Calif., also contains the NRMC Instruction 
describing the Administration of Nutritional Prepara- 

•Navy requesters may obtain copies of the Nutritional Preparations 
Formulary from the Medical Service Corps (MED 23) at BUMED. 


U.S. Navy Medicine 

TABLE 4. Nutritional Preparations Data Comparison 



Volume (ml) 
to meet 




FtlAfiAe Ttai 










Vivon&x HW 






* Recannended Route of Administration- OOral NG=Nasogastric (Tube) 











Eaialc PiUi 


Vivcniix HH 

•Preparations classified as Low Na contain < 500 rag Na per 1000 Calories 
•♦Preparations classified as Low K contain < 750mg K per 1000 Calories 
Source: Nutritional Preparations Formulary . (2) 

tions/Defined Formula Diets. (9) The purpose of the 
Instruction is to promulgate a standard policy for the 
selection, ordering, and administration of nutritional 
supplements, tube-feeding formulas, and enteral 
hyperalimentation solutions. It should be emphasized 
that the Nutritional Preparations Formulary does not 
promote the use of specific products, but rather 
provides the information base required by clinicians to 
make reasonable decisions concerning defined formula 
diet selection and product administration. 


The use of a reliable nutritional assessment protocol 
provides the clinician with the means of identifying the 
presence of nutritional deficiencies and directs the 
appropriate corrective nutritional therapy. When tradi- 
tional feeding methods are ineffective (due to signifi- 
cantly altered metabolic states, severe dietary restric- 
tions, physical impediments, or psychological prob- 
lems), defined formula diets provide an alternative 
means of achieving and maintaining optimal nutritional 
status. The Nutritional Preparations Formulary de- 
veloped at the Naval Regional Medical Center, Camp 
Pendleton, simplifies formula diet selection by provid- 

ing current data on commercially available products 
and assists the clinician in the nutritional support 
aspects of patient care. 


1 . Butterworth CE: The Skeleton in the Hospital Closet. Nutrition 
Today 9:4, 1974. 

2. Lamar SR, Hursig LS: Nutritional Preparations Formulary. 
Clinical Nutrition Branch, Food Management Service, Naval Regional 
Medical Center, Camp Pendleton, Calif. September 1978. 

3. Health Learning Systems, Inc: Malnutrition in the Hospital. 
Dialogues in Nutrition 2:2, June 1977. 

4. Ross Laboratories: An Illusion of Nutritional Health. A Film 
Outline, Columbus, Ohio, October 1977. 

5. Blackburn GL, et al: Nutritional and Metabolic Assessment of 
the Hospitalized Patient. J Parenteral and Enteral Nutrition 1:11, 

6. Gerhard JC, Lamar SR: "ORACLE" -Ongoing Ration Analysis 
of Cost. Logistics, and Efficiency. Food Management Service, Naval 
Regional Medical Center, Camp Pendleton, Calif., December 1976. 

7. Nutrition Support Service; Nutrition/Metabolism Laboratory; 
Cancer Research Institute; New England Deaconess Hospital; Har- 
vard Medical School, Boston, Mass. 

8. Pearson E, Soroff HS: Burns, In Nutritional Support of Medical 
Practice. Hagerstown, Harper & Row, 1977, p 224. 

9. NRMC Instruction 10110.3: Administration of Nutritional 
Preparations/Defined Formula Diets. Naval Regional Medical Cen- 
ter, Camp Pendleton, Calif. , 1 Oct 1978. 

Volume 70, August 1979 




In considering full-time training, MSC officers must 
evaluate the value of the training to his or her profes- 
sion, designator, projected rotation date, and obligated 
service incurred for training. Similarly, goals relating to 
continuing education should be evaluated on the basis 
of available opportunities during each future year, the 
educational and professional relevance of these oppor- 
tunities as well as the costs involved. 

In most cases, the programs listed below are avail- 
able to all MSC officers. Applications for full-time 
training are due by 1 Sept 1979 each year. Part-time 
training and continuing education applications are due 
in HSETC six weeks prior to commencement of the 
course requested. 

Full-time Doty Under Instruction (BUMEDINST 

1520.12). The various inservice and outservice pro- 
grams available are listed below. There is an active 
duty obligation incurred for all full-time training over 
26 weeks in length. BUMEDINST 1520.12 lists the 
active duty obligation incurred for participation in each 

Training in Civilian Institutions. Up to two years of 
undergraduate or graduate education at civilian educa- 
tional institutions may be provided to meet the training 
needs of the various specialties. 

U.S. Army/Baylor University Program in Health 
Care Administration, Fort Sam Houston, Tex. This is a 
two-phase masters degree program in health care ad- 
ministration. Forty-two weeks of didactic instruction at 
the Academy of Health Sciences, Fort Sam Houston, 
Tex., is followed by a 52-week administrative residency 
at selected naval medical facilities. 

Naval Postgraduate School, Monterey. Calif. This in- 
stitution offers masters level education in computer 
systems, financial, personnel, or human resource 
management. Program length varies from 12 to 18 
months depending upon previous training. 

Naval School of Health Sciences, Bethesda, Md. 

• Health Care Administration Program. This 9- 
month curriculum offers both health care administra- 
tion theory and application to prepare MSC officers for 

Navy health care managerial positions. Successful com- 
pletion of the program and other academic require- 
ments of the George Washington University may lead 
to the attainment of the Bachelor of Science degree in 
Health Care Administration. 

• Financial and Supply Management Training 
Course. This 12-week course is designed to prepare 
MSC officers for entry level positions in Medical De- 
partment financial and supply management. 

• Patient Services Course. A 5-week program that 
provides introductory training in patient services 
administration to MSC officers. 

Armed Forces Staff College, Norfolk, Va. This 9- 
month program offers a unique educational opportunity 
to study the concepts and principles of joint and com- 
bined military operations. The learning experiences of 
this program provide the student with an understand- 
ing of the U.S. military capability and the environment 
in which it operates, while currently applying tradi- 
tional service dogma to joint and combined operations. 

Industrial College of the Armed Forces, Fort McNair, 
Washington, B.C. A 10-month graduate level program 
in national security with emphasis on management of 
national resources under current and predicted environ- 
ments. Included is the study of both national and world 
interrelated military, economic, political, scientific, and 
social factors, with the objective of enhancing the 
preparation of selected military officers for positions of 
high trust in the national and international security 

Marine Corps Development and Education Com- 
mand, Quantico, Va. 

• Amphibious Warfare Course. A 9-month profes- 
sional military education program to prepare MSC 
officers for command and staff duties at battalion, 
squadron, regiment, group, and Marine amphibious 
brigade levels. Included is instruction in support pro- 
vided by the Navy in the conduct of amphibious opera- 
tions, command relationships, and interstaff coordina- 
tion requirements. 

• Command and Staff College. This course provides 
professional military education for command and staff 


U.S. Navy Medicine 

duty within the Marine Corps. It stresses the planning 
and conduct of force-in-readiness operations as a com- 
ponent of the balanced fleet. The course includes 
military management with emphasis on decision mak- 
ing, planning, programming, budgeting, and the use of 
computers. Considerable emphasis is placed on execu- 
tive leadership and effective communications. This is a 
10-month program. 

Blood Bank Fellowship at Walter Reed Army Medical 
Center, Washington, B.C. This 1-year course is de- 
signed to prepare Medical Technologists in the labora- 
tory science field as blood bank, directors. The program 
of instruction includes all phases of military blood bank- 
ing, blood grouping, and blood transfusion. 

Pharmacy Residency at NNMC Bethesda, Md., and 
NRMC San Diego, Calif. Provides a postgraduate learn- 
ing experience in institutional pharmacy practice. This 
program is certified by the American Society of Hospi- 
tal Pharmacists and is 1 year in length. 

Podiatry Residency at NRMC Oakland, Calif. This 1- 
year curriculum is designed to provide podiatric officers 
with a broad knowledge of the disciplines of medicine 
and surgery that relate significantly to the practice of 
military podiatry. 

Part-time Training (BUMEDINST 1500.7). This pro- 
gram provides partial sponsorship to officers taking 
evening or weekend courses in accredited civilian insti- 
tutions. Courses requested must be directly related to 
areas of Medical Department responsibility and asso- 
ciated with a degree attainment program. This program 
also permits those officers interested in full-time train- 
ing to begin advanced work on their degrees prior to 
selection for full-time training. The active duty obliga- 
tion incurred for this program is 2 years following com- 
pletion of the last approved course taken. 

Continuing Education (BUMEDINST 4651.1). Con- 
tinuing education is essential for maintaining profes- 
sional competence in light of the rapid changes in the 
technology, administration, and delivery of health care, 
and the increasing emphasis on accountability. Partici- 
pation in short courses and seminars as set forth in this 
program is one means through which MSC officers can 
keep abreast of the latest advances and events in their 

The reporting of all educational achievements to the 
Naval Military Personnel Command (NMPC), BUMED 
and HSETC is extremely important as this information 

becomes part of an officer's permanent record and is 
used in any decision making process such as assign- 
ment and promotion. 

Further assistance may be obtained by contacting 
LCDR Anthony R. Arnold, MSC, USN, Director, Medi- 
cal Service Corps Programs at the Naval Health Sci- 
ences Education and Training Command (Code 6), 
National Naval Medical Center, Bethesda, Md. 20014. 
Telephone: Autovon 295-0625, Commercial (202) 295- 


Many articles by Navy personnel appear each 
year in a variety of professional journals and other 
publications. U.S. Navy Medicine would like to 
include a monthly list of some of these articles 
written by Navy authors from all corps. If you 
have published recently and would like to share 
your research or perceptions with your colleagues, 
please send us the title, name, and issue of the 
publication in which your ankle appeared. 


The 86th Annual Meeting of the Association of Mili- 
tary Surgeons of the United States will be held from 2-6 
Oct 1979 at the Town and Country Hotel, San Diego, 

The meeting will emphasize continuing health educa- 
tion and professional excellence. Structured around a 
core program and supplemented by various section 
meetings and symposiums will be scientific and profes- 
sional presentations and panels of the highest caliber, 
with many distinguished guest speakers. 

Attendance at the 85th Annual Meeting was over 
3,500 and attendance at the 86th Annual Meeting is 
anticipated to be upwards of 4,000. Included will be dis- 
tinguished international medical leaders and the Com- 
manders and Directors of some 384 major hospitals 
within the Federal Medical System. 

As an organization accredited for continuing health 
care education, the Naval Health Sciences Education 
and Training Command, Bethesda, Md., certifies that 
the activities designated Category I in the Convention 
Program meet the criteria for that discipline, on an 
hour-for-hour basis. 

Naval Reserve Section 3-5 Oct 1979 (Category I) 

Chairman: CAPT Clarence J. Gibbs, Jr., MSC, 
USNR-R; USNR Session I: Symposium on Nuclear Dis- 
asters : CDR Attila Felsoory, MC, USNR-R and Team; 

Volume 70, August 1979 


USNR Session II: "Parasitic Diseases of Military Sig- 
nificance": CAPT J. Cerda, MC, USNR-R; USNR 
Session III: "Alcohol and Drug Abuse: Mobilization 
Readiness": Speaker: To be announced; USNR Session 
IV: "Tropical Diseases of Military Significance": 
Speaker: To be announced. 

The West Coast Nursing Symposium {Category I) 
presented by the Navy Nurse Corps under the sponsor- 
ship of the Naval Health Sciences Education and Train- 
ing Command will be held in conjunction with the 
AMSUS meeting. The symposium is approved for 10 
continuing education contact hours. 

The Oral Diagnosis Continuing Education Course 
(Category I) presented by the San Diego Naval Regional 
Dental Center will also be held in conjunction with the 
AMSUS meeting. This 21 -credit-hour program will 
provide a unique learning experience in oral diagnosis 
and medicine. 

For further information and an advanced registration 
form, write: Association of Military Surgeons of the 
U.S., P.O. Box 104, Kensington, Md. 20795. 


The Department of Extended Programs in Medical 
Education at the University of California School of Med- 
icine will sponsor the following course: 

Rheumatology Update— 1979 18-20 Oct 1979 

This course is designed to provide the practicing 
internist and rheumatologist with an update on current 
developments in the field of rheumatology. The course 
will concentrate on the clinical relevance of these new 
developments for the practicing physician. 

Topics to be covered include infections and the 
rheumatic disease, the connective tissue diseases, 
newer aspects in treatment of rheumatic diseases, and 
the role of the laboratory in managing rheumatic dis- 

For more information write or call: Extended Pro- 
grams in Medical Education, University of California, 
Room 569-U, Third and Parnassus Ave., San Francisco, 
Calif. 94143. Telephone (415) 666-4251. 


The Naval Health Sciences Education and Training 
Command (HSETC) in cooperation with Walter Reed 
Army Medical Center has produced a predeployment 
videotape titled "Prevention of Cold Weather In- 
juries," VM-11709. The program, narrated by Dr. 
Murray Hamlet of the Army Research Institute of En- 

vironmental Medicine, discusses the impact of cold 
environments upon the individual's body. He also dis- 
cusses preventive measures that reduce the incidence 
of various kinds of cold injuries. 

Copies of the videotape have been distributed to all 
naval hospital film libraries. In addition, they may be 
borrowed from: Audiovisual Resources Branch (Code 
221), HSETC, National Naval Medical Center, Bethes- 
da, Md. 20014. Telephone: Autovon 295-1226 or Com- 
mercial (202) 295-1226. 


U.S. Navy Medicine is requesting articles from field 
activities on topics associated with management within 
the ambulatory care environment. If you have original 
material on subjects which you feel may be of interest 
to other activities (i.e. outpatient records management, 
central appointment systems, outpatient budget re- 
quirements, etc.), please forward it for consideration. 
Articles of an activity or program description nature are 
welcome and should be received in this office by 15 Oct 


During the American College of Surgeons annual 
meeting, a Navy reception will be held 24 Oct 1979, 
from 1800 to 2000, in the Upper Summit Room of the 
Conrad Hilton Hotel, Chicago. For further information, 
contact: CAPT Robert R. Abbe, MC, USN, Chief of 
Surgery, Naval Regional Medical Center, Great Lakes, 
111. 60088. Telephone: Autovon 792-3629, Commercial 
(312) 688-3629. 


At a recent annual meeting of the Aerospace Physio- 
logist Society of the Aerospace Medical Association, 
two of the three annual awards were presented to Navy 
aerospace physiologists. LCDR W.W. Mcintosh, Head, 
Aviation Physiology Water Survival and Technical Of- 
fice, BUMED, received the Fred A. Hitchcock Award 
for Excellence in Aerospace Physiology. LT Curtis 
Glenn Armstrong, Jr., Aerospace Medical Safety Offi- 
cer, Naval Hospital, Cherry Point, N.C, received the 
Wiley Post Award for Operational Physiology. 

In addition to these honors won by Navy MSC offi- 
cers, the Aerospace Physiologist Society, the member- 
ship of which is made up of civilian and federal repre- 
sentation, elected CDR Paul D. Furr, (NMRDC/NAV- 
MAT) as President-elect for the 1980-81 term of office. 


U.S. Navy Medicine 



BUMED is currently implementing a plan to aug- 
ment the health care delivery teams by assigning Physi- 
cians Assistants (PAs) aboard all Aircraft Carriers. 
Their purpose will not be to replace physicians but 
rather to assist them as qualified and competent physi- 
cian extenders. All but three carriers currently have 
PAs assigned and the remainder are scheduled to re- 
ceive theirs at an appropriate date. For additional infor- 
mation, please see BUMEDINST 6550.5. 


Home monitors to protect youngsters with prolonged 
apnea against sudden infant death, or crib death, have 
been added to the CHAMPUS benefits package. 

To be covered, a monitor must be specifically pre- 
scribed by a physician who has diagnosed the infant as 
having prolonged apnea, a condition in which breathing 
stops for 20 seconds or longer. Prolonged apnea also 
includes stoppage of breathing for less than 20 seconds 
when associated with slowness of heartbeat, bluish dis- 
coloration of the skin or mucous membrane caused by 
too much or too little hemoglobin in the bloodstream, or 
absence of color in the skin. 

A documentation of both the episode or episodes that 
led to a diagnosis of prolonged apnea and the prescrip- 
tion for the home monitor must be included with the 
first claim for the equipment. That claim must also in- 
clude certification by the physician that he or she will 
maintain close, continuing supervision of the infant. 

Generally, CHAMPUS benefits will be payable only 
for rental of a home monitor. The only exception will 
occur when the organization that processes the claim (a 
CHAMPUS fiscal intermediary) determines that pur- 
chase would be less costly and approves a lease/pur- 
chase arrangement. 

Rental or lease payments made after 1 April 1978, 
will be considered for CHAMPUS cost sharing. Previ- 
ously, such equipment had been excluded from the 
CHAMPUS benefits package because it was considered 
to play a preventive role only. Recently, however, home 
monitors have evolved into an effective tool for manag- 
ing prolonged apnea and preventing sudden infant 

CHAMPUS officials have noted several services and 
supplies connected with home monitors that are not 
covered by the Program. These include: 

• A back-up electrical system or any alteration to liv- 
ing space required for the monitor. 

• Parental training sessions, including training in 
cardiopulmonary resuscitation or instruction in the use 
of the monitor when identified as a separate charge. 

• Any charge on the part of the company providing 
the monitor for making available medical, technical, 
and counseling assistance. 

• Hospitalization for monitoring a child with diag- 
nosed prolonged apnea unless hospitalization is neces- 
sary to treat underlying diseases or medical conditions 
that might be contributing to the problem. 

For additional information, contact a CHAMPUS 
advisor or fiscal intermediary. Information can also be 
obtained from OCHAMPUS, Aurora, Colo. 80045. 


A General Memorandum of Understanding between 
the National Cancer Institute (NCI) and the National 
Naval Medical Center (NNMC), Bethesda, Md., was 
signed on 18 July 1979 for the initiation of a collabora- 
tive research program in medical oncology. The NNMC 
will provide ward and laboratory space to accommodate 
a Medical Oncology Branch of the Division of Cancer 
Treatment, NCI. This branch will provide medical care 
for cancer patients at the NNMC and will conduct col- 
laborative research in the treatment of cancer. 

This link-up will provide closer ties between these 
neighboring institutions and will take advantage of 
unique resources not otherwise available to the other. 
The signatories of the agreement — VADM W.P. 
Arentzen (MC), Surgeon General, RADM Joseph T. 
Horgan (MC), Commanding Officer, National Naval 
Medical Center; Dr. Thomas Malone, Deputy Director, 
National Institutes of Health; and Dr. Arthur C. Upton, 
Director, National Cancer Institute — made clear in their 
remarks their major commitment to the success of this 
unique venture. They emphasized the efficiency and 
economy that this agreement will accomplish in the 
furtherance of the joint mission of the two institutions 

Volume 70, August 1979 



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